What is the management of patella alta in the Emergency Department (ED)?

From the Guidelines

Management of patella alta in the emergency department should focus on stabilization, pain control, and appropriate referral, with an emphasis on individualized assessment and treatment, as recommended by the most recent and highest quality study 1. The initial assessment should include an evaluation of the patient's symptoms, functional limitations, and fear of movement, as well as an objective evaluation of hip and knee strength, movement patterns, tissue tolerance to load, and patellofemoral joint structure and function, including patella alta or hypermobility 1. Key considerations in the management of patella alta include:

• Immobilization of the knee with a knee immobilizer or posterior splint in slight flexion (10-20 degrees) to reduce tension on the extensor mechanism
• Analgesia with NSAIDs, such as ibuprofen 400-600mg every 6 hours or naproxen 500mg twice daily, supplemented with acetaminophen 1000mg every 6 hours as needed
• Application of ice for 20 minutes every 2-3 hours to reduce swelling and pain
• Obtain standard knee radiographs, including AP, lateral, and sunrise views, to confirm patella alta diagnosis and rule out associated injuries
• The Insall-Salvati ratio (patellar tendon length/patellar length) greater than 1.2 on lateral view indicates patella alta
• Most cases require orthopedic referral within 1-2 weeks, but immediate consultation is necessary if there's an associated patellar dislocation, extensor mechanism disruption, or significant effusion
• Instruct patients to avoid weight-bearing or use crutches for partial weight-bearing until orthopedic evaluation Individualized knee-targeted exercise therapy, with or without hip exercises, should be delivered following a robust assessment of symptom severity and irritability, with exercise parameters modified accordingly, as recommended by the most recent and highest quality study 1. Education should underpin all interventions, providing a rationale for the delivery of a specific intervention plan, building confidence and understanding of the diagnosis, exploring the concept of pain not correlating with tissue damage, developing insight into the recovery journey and expected time frames, and promoting autonomy and reducing fear, as emphasized in the study 1. Supporting approaches, such as prefabricated foot orthoses, taping, and manual therapy, should be considered when rehabilitation and/or quality of life is hindered by elevated symptom severity and irritability, or high fear of movement, as recommended by the study 1. Movement/running retraining should be considered when symptoms are reasoned to be associated with task-specific biomechanics, as recommended by the study 1. If favourable outcomes are not observed after a realistic period (minimum 6 weeks), clinicians should revisit assessment findings to ensure that intervention(s) align well with their initial line of reasoning, and/or review patient engagement, as emphasized in the study 1.

From the Research

Management of Patella Alta in the Emergency Department (ED)

• The management of patella alta in the ED is not directly addressed in the provided studies, however, some information can be inferred from the available evidence.
• Patella alta is a risk factor for patellofemoral instability, and its management is crucial for treating this condition 2, 3.
• In the context of patellofemoral instability, surgical management may be necessary, and the choice of procedure depends on various factors, including the presence of patella alta 3.
• For acute pain management in the ED, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can be used, but their effectiveness may vary depending on the dose and individual patient response 4, 5.
• It is essential to consider the potential effects of NSAIDs on the healing process, particularly in the case of tendon injuries, as some studies suggest that these drugs may have a detrimental effect on healing strength 6.

Pain Management Options

• Non-opioid analgesics, such as NSAIDs and acetaminophen, are commonly used for acute pain management in the ED 4, 5.
• Regional blocks can be a useful part of a multimodal analgesic strategy for managing acute pain, especially in cases where systemic drugs are contraindicated or have significant side effects 5.
• The choice of pain management option depends on the individual patient's condition, the severity of pain, and the potential risks and benefits associated with each treatment 5.